Apply for Home Care Services

Complete this form and our care team will contact you within 24 hours to discuss your loved one's needs and schedule a free in-home assessment.

Client Information

Client First Name *

Client Last Name *

Date of Birth *

Gender

Client Home Address *

City *

ZIP Code *

Your Name *

Relationship to Client *

Phone Number *

Email Address *

Best Time to Call

Desired Start Date

Hours Per Week

Services Needed

Personal CareHomemakingCompanionshipMedication RemindersTransportationRespite CareOvernight CareLive-In Care (24/7)

Primary Diagnosis

Alzheimer's/DementiaParkinson'sStroke RecoveryDiabetesCOPD/RespiratoryPost-SurgeryMobility LimitationsGeneral Aging/Frailty

How Did You Hear About Us

Additional Information

By submitting this form you consent to Elegant Care contacting you by phone or email. Your information is kept private and secure.

Home Care Agency

Providing compassionate, professional non-medical home care services to seniors and adults throughout Chicago and Cook County, Illinois.

IDPH Licensed Agency

Serving Chicago & Cook County, Illinois